Drug-Induced

Conditions
Grace Carpenter, PharmD
 TABLE OF CONTENTS
Heparin-Induced
01 Thrombocytopenia

02 Drug-Induced Hyperthermia

03 Tardive Dyskinesia
 OBJECTIVES
Understand the pathophysiology and clinical presentations of
01 various drug-induced conditions.

Describe diagnostic methods for several drug-induced

02 conditions.

Analyze various treatment options for each drug-induced

03 conditions.
 Heparin-Induced
Thrombocytopenia
 Platelets < 150,000/μL
What is thrombocytopenia?
 Immune response due to formation of
What is HIT? antibodies against complexes of heparin
and platelet factor 4 (PF4).

Eposure to ANY form of heparin (low

What
Heparin-Induced causes HIT?
molecular weight heparin, unfractionated
heparin) administered by any route (IV, SQ).

Thrombocytopenia
Antibodies are said to be
produced in 2-17% of
patients exposed to
heparin products,
depending on the exact
product type.

Arepally GM. Heparin induced-thrombocytopenia. Blood.

2017;129(21):2864-2872. doi:10.1182/blood-2016-11-709873
 Things to think about…
What is your patient’s baseline platelet count?

Are other markers (hemoglobin, hematocrit) trending down?

Are there any other possible causes of thrombocytopenia in

your patient outside of HIT?
 Causes of Thrombocytopenia
- Immune thrombocytopenia (ITP): Antiphospholipid syndrome, systemic lupus erythematosus,
HIV, CMV, VZV, hepatitis C, EBV, TTP

- Cancer

- Alcohol use

- Chronic liver disease

- Disseminated intravascular coagulation (DIC)

- Drug-Induced: Linezolid, beta-lactams, carbamazepine, phenytoin, Bactrim, valproic acid,

vancomycin, quinine, quinidine

- Pregnancy: HELLP syndrome, gestational thrombocytopenia, preeclampsia

 Scoring Tool
Thrombocytopenia Timing of platelet fall

4T Score

Other causes of Thrombosis or

thrombocytopenia other sequelae

Determines low (0-3 pts),

medium (4-5 pts), or high
(6-8 pts) probability of HIT
Arepally GM. Heparin induced-thrombocytopenia. Blood. 2017;129(21):2864-2872.
doi:10.1182/blood-2016-11-709873
 MdCalc 4T Score

4Ts Score for Heparin-Induced Thrombocytopenia

(mdcalc.com)

4Ts Score for Heparin-Induced Thrombocytopenia. MdCalc. Accessed January 29, 2024.
https://www.mdcalc.com/calc/1787/4ts-score-heparin-induced-thrombocytopenia
 Diagnostic Testing
Heparin-Induced Platelet
Antibody Test
Detects presence of heparin-induced platelet antibodies
High sensitivity, low specificity
Presented as a number on a scale
Serotonin Release
If +, reflex
Assay (SRA)
Patient serum is combined with donor platelets;
serotonin is released with exposure to heparin
High specificity, lower sensitivity
Presented as a positive or negative result

ELISA SRA Interpretation

- - HIT unlikely

+ - HIT unlikely

- + Likely

+ + Confirmed

Arepally GM. Heparin induced-thrombocytopenia. Blood.

2017;129(21):2864-2872. doi:10.1182/blood-2016-11-709873
 HIT Treatment
STOP ANY
HEPARIN-CONTAINING
PRODUCTS!

Initiate a non-heparin
anticoagulant…

Arepally GM. Heparin induced-thrombocytopenia. Blood.

2017;129(21):2864-2872. doi:10.1182/blood-2016-11-709873
What IV non-heparin anticoagulants are
available?
 Bivalirudin (Angiomax ®) Argatroban
- IV direct thrombin inhibitor - IV direct thrombin inhibitor
- Renally adjusted - Hepatically adjusted
- Initial: 0.15-0.2 mg/kg/hr - Initial: 2 mcg/kg/min
- CrCl 30-60: 0.08-0.12 - Child-Pugh B: 0.5
mg/kg/hr mcg/kg/min
- CrCl < 30: 0.04-0.07 - Child-Pugh C: 0.25
mg/kg/hr mcg/kg/min
- $460 per 100 mg - $9.36 to $245 per 100 mg

Bivalirudin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January
29, 2024. http://online.lexi.com

Argatroban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed
January 29, 2024. http://online.lexi.com
 Bivalirudin Argatroban

- Monitor aptt q2-4h depending on starting

- Monitor aptt q4h; after two consecutive goal
rate. After two consecutive goal aptts, may
aptts, may evaluate qAM.
evaluate qAM.
- Monitor CBC qAM.
- Monitor CBC qAM.
- Monitor HIT antibody and/or SRA results.
- Monitor HIT antibody and/or SRA results.
What non-heparin, non-IV anticoagulants
are available for treatment of HIT?
 Fondaparinux (Arixtra ®)
- SQ Factor Xa inhibitor
- HIT Treatment Dosing
- < 50 kg: 5 mg SQ QD
- 50-100 kg: 7.5 mg SQ QD
- > 100 kg: 10 mg SQ QD
- Arixtra = $157 per syringe
- NO ANTIDOTE AVAILABLE

Fondaparinux. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed
January 29, 2024. http://online.lexi.com
 Arixtra Controversy
Controversy existed in regard to Arixtra in the setting of HIT due to it being a
synthetic heparin, but according to a 2020 retrospective meta-analysis published
by the AHA:

- Arixtra significantly reduced incidence of VTE, amputation, gangrene, and HIT-related

mortality when compared to a compilation of standard IV non-heparin anticoagulants.

Good to use
off-label for
HIT ✔

Sousa P, Teixeira R, Lourenco C, et al. Abstract 15944: Fondaparinux: a low-hanging fruit in

heparin-induced thrombocytopenia. Circulation. 2020;142:A15944.
doi:10.1161/circ.142.suppl_3.15944
 Oral Anticoagulants

- Warfarin (goal INR of 2-3)

- Overlap with IV anticoagulant for ≥ 5 days
once platelets have recovered
- Rivaroxaban 15 mg BID x 21 days (or until
platelet recovery) followed by 20 mg QD
- Apixaban 10 mg BID x 7 days (or until platelet
recovery), followed by 5 mg BID

Warfarin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024. http://online.lexi.com

Rivaroxaban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024. http://online.lexi.com

Apixaban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024. http://online.lexi.com
 Xarelto in HIT Study
Prospective study
Methods
- 16 patients treated with Xarelto

Study Positive HIT antibodies + positive SRA

Inclusion
Criteria No diagnoses more compelling than HIT

Primary Confirmed and symptomatic thrombotic event

Outcome within 30 days in groups A1, A2, & B

Secondary Incidence of major bleeding

Outcomes Time to platelet recovery (plts ≥ 150 K/μL)

A literature review was also completed on 8

other published articles (24 total patients)
evaluating patients with HIT receiving Xarelto.
Warkentin TE, Pai M, Linkins L. Direct oral anticoagulants for treatment of HIT:
update of Hamilton experience and literature review. Blood.
2017;130(9):1104-1113. doi:10.1182/blood-2017-04-778993
 Xarelto in HIT Study Results
Study

Literature
Review

Conclusion: Not only does it appear appropriate to use Xarelto for

the treatment of subacute HIT (plts ≥ 150 K/μL), but also at initial
Warkentin TE, Pai M, Linkins L. Direct oral
anticoagulants for treatment of HIT: update of
diagnosis of acute HIT.
Hamilton experience and literature review. Blood.
2017;130(9):1104-1113.
doi:10.1182/blood-2017-04-778993
 In patients with HIT, an anticoagulant should be
continued for at least:
3 months in patients who experienced thrombosis

OR
1 month in patients who had no thrombosis

Arepally GM. Heparin induced-thrombocytopenia. Blood.

2017;129(21):2864-2872. doi:10.1182/blood-2016-11-709873
Drug-Induced
Hyperthermia
 Malignant Hyperthermia
Life-threatening pharmacogenetic disorder
What is it?
caused by anesthesia medications.

Implicated medications Desflurane, sevoflurane, succinylcholine

Extreme fever, muscle rigidity, hypercarbia,

Symptoms
tachycardia

Who oversees treatment Malignant Hyperthermia Association of the

and follow-up? United States (MHAUS)

How is MH susceptibility Children and siblings of an MH patient have

inherited? a 50% chance of being MH-susceptible.

Healthcare Professionals. Malignant Hyperthermia Association of the United States. Accessed

February 4, 2024. https://www.mhaus.org/healthcare-professionals/
 Management of Malignant Hyperthermia
DISCONTINUE THE OFFENDING AGENT!

- Call MHAUS U.S. Hotline → 1-800-644-9737

- Continue surgery if necessary with alternative agents (nitrous oxide,
non-depolarizing neuromuscular agents).
- Hyperventilate the patient with 100% oxygen to allow for
metabolization of inhaled anesthetic gases.
- Dantrolene (located in MH cart): Give 2.5 mg/kg through large-bore
IV, repeating dose q5min until symptoms resolve
- Cool patient if > 39 ℃ (102.2℉), treat hyperkalemia/arrhythmias

Healthcare Professionals. Malignant Hyperthermia Association of the United States. Accessed Dantrolene. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January
February 4, 2024. https://www.mhaus.org/healthcare-professionals/ 29, 2024. http://online.lexi.com
 Follow Up After MH Crisis
● Monitor ECG, temperature, muscle
01 Transfer to ICU rigidity, K, CK, HR, RR

● Allergy documentation to anesthetic

02 Document Allergy gases and succinylcholine →
LIFELONG AVOIDANCE

● Ran by the Malignant Hyperthermia

03 Report to MH Registry Association of the U.S. (MHAUS)

● Muscle biopsy (gold standard)

04 MH Diagnostic Testing ● Genetic testing

Healthcare Professionals. Malignant Hyperthermia Association of the United States. Accessed

February 4, 2024. https://www.mhaus.org/healthcare-professionals/
 MH Diagnostic Testing

Testing for MH Susceptibility. European Malignant Hyperthermia Group. Accessed February 6,

2024. https://www.emhg.org/testing-for-mh
 Dantrolene
- Mechanism: Binds to RYR1 receptor to prevent release of
excess calcium from the sarcoplasmic reticulum.

- Requirement → within 10 minutes of operating facility

- In each Dantrium ® vial, there are 3 grams of mannitol; a 90

kg patient would receive ~ 34 grams of mannitol at a
minimum.

- Ryanodex ® = 3 vials for 72 kg patient

- Dantrium ® = 36 vials for 72 kg patient

Healthcare Professionals. Malignant Hyperthermia Association of the United States. Accessed Dantrolene. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January
February 4, 2024. https://www.mhaus.org/healthcare-professionals/ 29, 2024. http://online.lexi.com
 Neuroleptic Malignant Syndrome
An idiopathic life-threatening condition caused by exposure to antipsychotic medications (most
commonly) or other dopamine antagonists, such as metoclopramide or prochlorperazine.

Per DSM-IV-TR, a patient must have at least both major findings AND two minor findings in
the presence of recent antipsychotic exposure:

Major Findings Fever, muscle rigidity

Sweating, tachycardia, altered arterial

tension, elevated WBCs, altered
Minor Findings consciousness, tremor, urinary-fecal
incontinence, elevated creatinine
phosphokinase

Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876.

American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., Text Revision. Washington DC: American Psychiatric Association; 2000.
 Neuroleptic Malignant Syndrome
High-potency antipsychotics as well as high doses, IV/IM/SQ route, and quick titration causes
increased risk for NMS.

Highest potency → haloperidol, fluphenazine

Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876.
 Serotonin Syndrome
Caused by excess serotonergic activity (usually after
starting more than one serotonergic drug or a following a
serotonergic drug overdose).

What medications may cause serotonin syndrome?

- Selective serotonin reuptake inhibitors (SSRIs), serotonin and
norepinephrine reuptake inhibitors (SNRIs), monoamine
oxidase inhibitors (MAOIs) and tricyclic antidepressants (TCAs)
- Triptans
- Opioids (methadone, fentanyl, meperidine, tramadol)
- Antiemetics (ondansetron, metoclopromide)
- Miscellaneous: Linezolid, St. John’s Wort, dextromethorphan,
trazodone, cyclobenzaprine, mirtazepine

Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112-1120.

doi:10.1056/NEJMra041867
Serotonin Syndrome Symptoms

Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112-1120. doi:10.1056/NEJMra041867
Hunter Criteria Spontaneous
clonus

Yes No

SEROTONIN Inducible OR ocular

SYNDROME clonus +
Agitation OR Diaphoresis

No Yes

Tremor + SEROTONIN
Hyperreflexia SYNDROME

No Yes
Hypertonic + Temp > SEROTONIN
38℃ + ocular OR SYNDROME
inducible clonus

No Yes

NOT serotonin SEROTONIN

syndrome SYNDROME

Dunkley EJC, Isbister GK, Sibbritt D, et al. The Hunter serotonin toxicity criteria: simple and accurate diagnostic decision rules for serotonin
toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109
 Management of SS/NMS
DISCONTINUE THE OFFENDING AGENT!

Supportive Care
- Oxygen (goal = SpO2 ≥ 94°F)
- IV fluids
- Telemetry → correct vital signs
- Prefer chemical > physical restraint
- Sedation, paraylsis, and intubation if
necessary (temperature > 106°F)
- Physical cooling measures
Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome.
Am J Psychiatry. 2007;164(6):870-876.
NMS/SS Pharmacologic Management
Both Disorders18 Serotonin Syndrome19 Neuroleptic Malignant Syndrome11, 20, 21

Chemical Restraint: Cyprohepatidine: 12 mg

Bromocriptine: 2.5 mg PO q6-12h
Lorazepam 0.5-2 mg IV PO x 1, then 2 mg
q4-6h q2hours until clinical
Amantadine: 100 mg PO QD
response
Hypertension: Esmolol, - Maintenance: 4-8 mg
Dantrolene: 1-2.5 mg/kg IV, then 1 mg/kg q6h
nicardipine, nitroprusside PO q6hours prn

Increased doses may be needed to reach symptom resolution and tapers during
discontinuation may also be necessary.
Tardive Dyskinesia
 Tardive Dyskinesia
A disorder precipitated by exposure to
dopamine antagonists (antipsychotics,
What is TD?
metoclopramide, prochlorperazine) resulting
in abnormal involuntary movements.

Bhidayasiri R, Fahn S, Weiner W, et al. Evidence-based guideline: treatment of tardive

syndromes. Neurology. 2013;81(5):463-469. doi:10.1212/WNL.0b013e31829d86b6
 Schooler-Kane Criteria
1. 3 months of antipsychotic exposure (continuous or discontinuous)
2. Abnormal, involuntary movements of at least moderate severity in one or
more body regions OR mild severity in 2 or more body regions [correlate
with a rating scale such as AIMS (see next slide)]
3. Patient must be free of any other condition that could cause these abnormal
movements.

Patient meets all 3 criteria = probable TD

Correll C, Kane JM, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia and advances in
treatment. J Clin Psychiatry. 2017;78(8):1136-1147. doi:10.4088/JCP.tv17016ah4c
AIMS Scale
 Prevention of Tardive Dyskinesia
1. Limit long-term use of implicated medications whenever possible
2. Choose alternative medications when they are available
3. Use the lowest effective dose when implicated medications are necessary
4. Use a single agent rather than several agents if possible
5. Perform regular TD assessments

Correll C, Kane JM, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia and advances in
treatment. J Clin Psychiatry. 2017;78(8):1136-1147. doi:10.4088/JCP.tv17016ah4c
 TD Treatment
DISCONTINUE OFFENDING AGENT, if
possible (slowly)

Transition to second Adjunct:

Vesicular Monoamine
generation agent Transport 2 (VMAT2)
(olanzapine, risperidone) Inhibitors, with or without
antipsychotic use
Clonazepam 0.5 mg PO QD
Amantadine 100 mg PO QD
Onabotulinum Toxin A (for
cervical dystonia or
blepharospasm)

Bhidayasiri R, Fahn S, Weiner W, et al. Evidence-based guideline: treatment of tardive syndromes. Neurology.
2013;81(5):463-469. doi:10.1212/WNL.0b013e31829d86b6

Correll C, Kane JM, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia and advances in Amantadine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed
treatment. J Clin Psychiatry. 2017;78(8):1136-1147. doi:10.4088/JCP.tv17016ah4c January 29, 2024. http://online.lexi.com

Clonazepam. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024. Onabotulinum toxin A. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL.
http://online.lexi.com Accessed January 29, 2024. http://online.lexi.com
 VMAT2 Inhibitors
Tetrabenazine (Xenazine): 50 mg/day in 2-3 divided doses (max of 150 mg/day)

Valbenazine (Ingrezza): 40 mg PO QD
- Increase to 80 mg after one week
- Note: Recommended max dose if 40 mg/day if taking a
strong CYP2D6 or CYP3A4 inhibitors.

Deutetrabenazine (Austedo):
- IR: 6 mg PO BID (max of 48 mg/day)
- ER: 12 mg PO QD (max of 48 mg/day)
- Note: Recommended max dose of 36 mg/day if taking
strong CYP2D6 inhibitors

Side Effects: Drowsiness/sedation, insomnia, depression, anxiety

Correll C, Kane JM, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia Valbenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed
and advances in treatment. J Clin Psychiatry. 2017;78(8):1136-1147. doi:10.4088/JCP.tv17016ah4c February 5, 2024. http://online.lexi.com

Tetrabenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed Deutetrabenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed
February 5, 2024. http://online.lexi.com February 5, 2024. http://online.lexi.com
Refractory TD

Szczakowska A, Gabryelska A, Gawlik-Kotelnicka O, et al. Deep brain simulation in the treatment

of tardive dyskinesia. J Clin Med. 2023;12(5):1868. doi:10.3390/jcm12051868
Questions?
CREDITS: This presentation template was created by
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 References
1. Arepally GM. Heparin induced-thrombocytopenia. Blood. 2017;129(21):2864-2872. doi:10.1182/blood-2016-11-709873
2. 4Ts Score for Heparin-Induced Thrombocytopenia. MdCalc. Accessed January 29, 2024.
https://www.mdcalc.com/calc/1787/4ts-score-heparin-induced-thrombocytopenia
3. Bivalirudin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
4. Argatroban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
5. Fondaparinux. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
6. Sousa P, Teixeira R, Lourenco C, et al. Abstract 15944: Fondaparinux: a low-hanging fruit in heparin-induced
thrombocytopenia. Circulation. 2020;142:A15944. doi:10.1161/circ.142.suppl_3.15944
7. Warfarin. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
8. Rivaroxaban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
9. Apixaban. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
10. Warkentin TE, Pai M, Linkins L. Direct oral anticoagulants for treatment of HIT: update of Hamilton experience and
literature review. Blood. 2017;130(9):1104-1113. doi:10.1182/blood-2017-04-778993
11. Dantrolene. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
 References
12. Healthcare Professionals. Malignant Hyperthermia Association of the United States. Accessed February 4, 2024.
https://www.mhaus.org/healthcare-professionals/
13. Testing for MH Susceptibility. European Malignant Hyperthermia Group. Accessed February 6, 2024.
https://www.emhg.org/testing-for-mh
14. Strawn JR, Keck PE, Caroff SN. Neuroleptic malignant syndrome. Am J Psychiatry. 2007;164(6):870-876.
15. American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed., Text Revision.
Washington DC: American Psychiatric Association; 2000
16. Boyer EW, Shannon M. The serotonin syndrome. N Engl J Med. 2005;352:1112-1120. doi:10.1056/NEJMra041867
17. Dunkley EJC, Isbister GK, Sibbritt D, et al. The Hunter serotonin toxicity criteria: simple and accurate diagnostic decision
rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109
18. Lorazepam. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
19. Cyproheptadine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
20. Bromocriptine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
21. Amantadine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed January 29, 2024.
http://online.lexi.com
22. Bhidayasiri R, Fahn S, Weiner W, et al. Evidence-based guideline: treatment of tardive syndromes. Neurology.
2013;81(5):463-469. doi:10.1212/WNL.0b013e31829d86b6
23. Correll C, Kane JM, Citrome LL. Epidemiology, prevention, and assessment of tardive dyskinesia and advances in
treatment. J Clin Psychiatry. 2017;78(8):1136-1147. doi:10.4088/JCP.tv17016ah4c
 References
24. Clonazepam. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed February 5, 2024.
http://online.lexi.com
25. Onabotulinum toxin A. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed February 5,
2024. http://online.lexi.com
26. Tetrabenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed February 5, 2024.
http://online.lexi.com
27. Valbenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed February 5, 2024.
http://online.lexi.com
28. Deutetrabenazine. Lexi-Drugs. Lexicomp. Wolters Kluwer Health, Inc. Riverwoods, IL. Accessed February 5, 2024.
http://online.lexi.com
29. Szczakowska A, Gabryelska A, Gawlik-Kotelnicka O, et al. Deep brain simulation in the treatment of tardive
dyskinesia. J Clin Med. 2023;12(5):1868. doi:10.3390/jcm12051868